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Case: Andrew is a 16yo post-pubertal male without any past medical history who comes to clinic for his annual well-child check. His vitals at triage showed a blood pressure of 142/92. You note that he was seen in urgent care twice in the last 2 months with a similarly high blood pressures. His BMI is >95th percentile. How should you address his blood pressure today? Specifically, what further workup and/or treatment should be undertaken?

Diagnosis

How is high blood pressure classified? (based on The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents)

Hypertension is defined as an average systolic blood pressure (SBP) and/or diastolic BP (DBP) that is ≥95th percentile for gender, age, and height on 3 occasions.

These 3 occasions needs to be separated by days-weeks

Note: Measures obtained by oscillometric devices (aka automatic BP machines) that exceed the 90th percentile should be repeated by auscultation.

Prehypertension in children is defined as average SBP or DBP levels that are ≥90th percentile but <95th percentile.

As with adults, adolescents with BP levels >120/80 mmHg should be considered prehypertensive.

A patient with BP levels ≥95th percentile in a physician’s office or clinic, who is normotensive outside a clinical setting, has “white-coat hypertension.”

Ambulatory BP monitoring (ABPM) is usually required to make this diagnosis.

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Epidemiology

The prevalence of primary and secondary hypertension is 4.5% and 13%, respectively (Gupta-Malhotra et al, 2015)

Given low screening rates, true prevalence may be higher

Children with essential (primary) hypertension tend to be older (>6), have a family history of hypertension (Gupta-Malhotra et al, 2015)

Conversely, infants and preschool-aged children with elevated blood pressure are more likely to have a secondary form of hypertension.

Etiology & Workup

While secondary causes of hypertension are more common in children than adults, children can also have primary hypertension (see Table below

<1yr old (%)

1-5 years (%)

6-12 years (%)

13-19years (%)

Respiratory (61)

Respiratory (29)

Essential (57)

Essential (49)

Renal (13)

Renal (27)

Renal (27)

Renal (20)

Medication Related (9)

Essential (19)

Neurological (7)

Medication Related (11)

Table 1: Most common causes of hypertension by age (adapted fromGupta-Malhotra et al, 2015)

Workup for secondary causes should be individualized

Children with BPs ≥95th percentile (stage 1 hypertension) should have the following (NHBPEP, 2004; Ingelfinger JR, 2014):

Back to the Case: Upon seeing Andrew, you repeat his blood pressure manually, which is also high. He has no other “red flags” on history or exam. Given his age and comorbidities (obesity), Andrew most likely has essential hypertension (3 readings >140/90). Initial workup should include: basic labs (BMP, CBC, and UA) and imaging (renal ultrasound and ECHO). Provided these are all reassuring, he should first undergo lifestyle interventions, with medical management initiated if his BPs do not normalize.

References

“The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.” Pediatrics Aug 2004, 114 (Supplement 2) 555-576